Provider Demographics
NPI:1942307384
Name:RAO, CHAMKIRKISHTIAH PANDURANGA
Entity Type:Individual
Prefix:DR
First Name:CHAMKIRKISHTIAH
Middle Name:PANDURANGA
Last Name:RAO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CHAMKURKISHTIAH
Other - Middle Name:PANDURANGA
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:19 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOHAWK
Mailing Address - State:NY
Mailing Address - Zip Code:13407-1024
Mailing Address - Country:US
Mailing Address - Phone:315-866-7766
Mailing Address - Fax:
Practice Address - Street 1:19 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOHAWK
Practice Address - State:NY
Practice Address - Zip Code:13407-1024
Practice Address - Country:US
Practice Address - Phone:315-866-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150274207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00803269Medicaid